Author Archives: gutsandgrowth

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About gutsandgrowth

I am a pediatric gastroenterologist at GI Care for Kids (previously called CCDHC) in Atlanta, Georgia. The goal of my blog is to share some of my reading in my field more broadly. In addition, I wanted to provide my voice to a wide range of topics that often have inaccurate or incomplete information. Before starting this blog in 2011, I would tear out articles from journals and/or keep notes in a palm pilot. This blog helps provide an updated source of information that is easy to access and search, along with links to useful multimedia sources. I was born and raised in Chattanooga. After graduating from the University of Virginia, I attended Baylor College of Medicine. I completed residency and fellowship training at the University of Cincinnati at the Children’s Hospital Medical Center. I received funding from the National Institutes of Health for molecular biology research of the gastrointestinal tract. During my fellowship, I had the opportunity to work with some of the most amazing pediatric gastroenterologists and mentors. Some of these individuals included Mitchell Cohen, William Balistreri, James Heubi, Jorge Bezerra, Colin Rudolph, John Bucuvalas, and Michael Farrell. I am grateful for their teaching and their friendship. During my training with their help, I received a nationwide award for the best research by a GI fellow. I have authored numerous publications/presentations including original research, case reports, review articles, and textbook chapters on various pediatric gastrointestinal problems. In addition, I have been recognized by Atlanta Magazine as a "Top Doctor" in my field multiple times. Currently, I am the vice chair of the section of nutrition for the Georgia Chapter of the American Academy of Pediatrics. In addition, I am an adjunct Associate Clinical Professor of Pediatrics at Emory University School of Medicine. Other society memberships have included the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN), American Academy of Pediatrics, the Food Allergy Network, the American Gastroenterology Association, the American Association for the Study of Liver Diseases, and the Crohn’s and Colitis Foundation. As part of a national pediatric GI organization called NASPGHAN (and its affiliated website GIKids), I have helped develop educational materials on a wide-range of gastrointestinal and liver diseases which are used across the country. Also, I have been an invited speaker for national campaigns to improve the evaluation and treatment of gastroesophageal reflux disease, celiac disease, eosinophilic esophagitis, hepatitis C, and inflammatory bowel disease (IBD). Some information on these topics has been posted at my work website, www.gicareforkids.com, which has links to multiple other useful resources. I am fortunate to work at GI Care For Kids. Our group has 17 terrific physicians with a wide range of subspecialization, including liver diseases, feeding disorders, eosinophilic diseases, inflammatory bowel disease, cystic fibrosis, DiGeorge/22q, celiac disease, and motility disorders. Many of our physicians are recognized nationally for their achievements. Our group of physicians have worked closely together for many years. None of the physicians in our group have ever left to join other groups. I have also worked with the same nurse (Bernadette) since I moved to Atlanta in 1997. For many families, more practical matters about our office include the following: – 14 office/satellite locations – physicians who speak Spanish – cutting edge research – on-site nutritionists – on-site psychology support for abdominal pain and feeding disorders – participation in ImproveCareNow to better the outcomes for children with inflammatory bowel disease – office endoscopy suite (lower costs and easier scheduling) – office infusion center (lower costs and easier for families) – easy access to nursing advice (each physician has at least one nurse) I am married and have two sons (both adults). I like to read, walk/hike, bike, swim, and play tennis with my free time. I do not have any financial relationships with pharmaceutical companies or other financial relationships to disclose. I have helped enroll patients in industry-sponsored research studies.

Anti-TNF Therapies: Safe in Pregnancy

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According a review (Inflamm Bowel Dis 2014; 20: 1862-69) of 5 studies with 1216 patients, “the use of anti-TNFα therapy does not seem to increase the risk of unfavorable pregnancy outcomes among women with IBD, although the optimal timing of therapy through pregnancy and the postpartum period was not assessed.”

Other important points:

  • “Current recommendations suggest that anti-TNFα therapies be continued during the first 2 trimesters of pregnancy.”  Withholding of infliximab and adalimumab during the third trimester is due to concerns of increased drug levels in infants.
  • Live virus vaccination should “be avoided for the first 6 months in children who had exposure to anti-TNFα therapies in utero.”

Related blog posts:

Back to Basics: Acid-Base Disturbances

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A good review on acid-base disturbances: NEJM 2014; 371: 1434-45.  This is good reading for those needing a refresher on any of the following:

  • Metabolic acidosis: -high anion-gap vs. low anion-gap (Table 2)
  • Metabolic alkalosis -mainly due to loss of gastric fluid and use of diuretics.
  • Respiratory acidosis -associated with hypoventilation
  • Respiratory alkalosis -associated with hyperventilation

Here’s a link: http://www.nejm.org/doi/full/10.1056/NEJMra1003327

A few useful pointers:

  • Lactic acidosis  –“roughly half the patients with serum lactate levels between 3.0 and 5.0 mmol per liter have an anion gap within the reference range.”
  • Anion gap is affected by hypoalbuminemia.  “For every decrement of 1 g per deciliter in the serum albumin concentration, the calculated anion gap should be increased by approximately 2.3 to 2.5 mmol per liter.”
  • Low anion gap mainly due to loss of bicarbonate: GI conditions (like diarrhea or other GI fluid losses), renal losses of bicarbonate (RTAs, medicine-induced), decreased renal acid excretion, or other (eg. saline resuscitation, hyperalimentation (lysine, histidine, or argentine hydrochloride, cholestyramine, and other causes).
  • High anion gap: overproduction of acid (lactic acidosis, ketoacidosis –DKA, alcoholic).  Lactic acidosis can be due to D-lactic acidosis in short bowel syndrome or due to L-lactic acidosis (type A hypoxic, type B nonhypoxic -related to numerous medicines/intoxications/thiamine deficiency), advanced renal failure, impaired lactic clearance in liver failure, rhabdomyolysis, penicillin-derived antibiotics, and pyroglutamic acid.

Figure 1 provides an algorithm for sorting out acedemias including use of urinary anion gaps and Figure 2 does the same for alkalemias.

Case Report of Poor Growth, Splenomegaly, and Pneumopathy

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From AGA twitter feed link/Gastroenterology Volume 147, Issue 4, Pages e3–e4, October 2014.:

Question: A 6-year-old Caucasian boy presented with recurrent episodes of fatigue, abdominal pain, and diarrhea. In between these episodes, he had good exercise tolerance. He has never traveled outside Hawaii and Western Europe, had no known allergies, and was not taking any medication. An unexplained splenomegaly had first been discovered 6 months ago.

Clinical examination was unremarkable except for growth below the expected range (Figure A) and splenomegaly with a palpable spleen 4 cm below coastal margin. There was no heart murmur, dyspnea, clubbing, icterus, eczema, or lymphadenopathy. Neurologic development was adequate for age.

Laboratory workup showed no anemia and normal lymphocyte subsets. The thrombocytes were in the low normal range (155 × 109/L) and aspartate transaminase (56 U/L) was mildly elevated. The fecal pancreatic elastase and calprotectin were in the normal range. Ultrasonography revealed enlarged liver and spleen without evidence of portal vein thrombosis or focal lesions. A chest x-ray displayed bilateral interstitial lung disease with a reticulonodular pattern.

What is the most likely diagnosis? 

Here’s the link: Answer and explanation.

Lack of Value of Breakfast for Weight Loss

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In contrast to previous reports (see previous blog: Skipping breakfast -boomerang effect for obesity …), a recent Study Indicates Lack of Weight Loss by Adding Breakfast (from USA Today).  Here’s an excerpt

Grandmothers, marketers and researchers alike have long touted breakfast as a must-have meal, praising its ability to rev up metabolism, stave off hunger, help calorie watchers keep their weight in check and improve concentration and cognitive function.

But for all the glowing endorsements, there have also been warnings against over-hyping the power of breakfast.

That concern was raised again this summer when a study comparing groups of overweight and obese adults dieters found that eating or skipping breakfast made no difference in how much weight was lost over a 16-week period.

“Our simple question was (when it comes to weight loss), does it help to eat breakfast? And the answer seems to be probably not,” says David Allison, director of the University of Alabama at Birmingham Nutrition Obesity Research Center and senior investigator of the study reported in the American Journal of Clinical Nutrition.

Scarier than Ebola -the Flu

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Scarier than Ebola  — From NY Times (an excerpt)

“Do me a favor. Turn away from the ceaseless media coverage of Ebola in Texas — the interviews with the Dallas nurse’s neighbors, the hand-wringing over her pooch, the instructions on protective medical gear — and answer this: Have you had your flu shot? Are you planning on one?

During the 2013-2014 flu season, according to the Centers for Disease Control and Prevention, only 46 percent of Americans received vaccinations against influenza, even though it kills about 3,000 people in this country in a good year, nearly 50,000 in a bad one….

On CNN on Monday night, a Dallas pediatrician was asked about what she had advised the families she sees. She said that she urged them to have their children “vaccinated against diseases that we can prevent,” and that she also stressed frequent hand-washing. Ebola or no Ebola, it’s a responsible — and frequently disregarded — way to lessen health risks.

So are these: fewer potato chips. Less sugary soda. Safer sex. Tighter restrictions on firearms. More than 30,000 Americans die from gunshots every year. Anyone looking for an epidemic to freak out about can find one right there.”

Early Antibiotics and Obesity

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A recent JAMA Pediatrics study showed that early and frequent antibiotics were associated with an increase risk of obesity.  Here’s a link to the LA Times summary of this article:  Antibiotics and Obestiy (LA Times)

Here’s an excerpt:

Broad-spectrum antibiotics — including amoxicillin, tetracycline, streptomycin, moxifloxacin and ciprofloxacin — are intended for treatment of major systemic infections, in cases where the bacteria causing the illness has not been identified, or where a patient is under attack by a strain of bacteria resistant to standard antibiotics. While they can be highly effective, their antibiotic action is indiscriminate, and beneficial bacteria in the body are often killed off as collateral damage.

The latest study tapped the medical records of 64,580 babies and children in and around Philadelphia. It was published Monday [Sept 29, 2014] in the journal JAMA Pediatrics.

The heightened risk of obesity linked to antibiotic use was not huge: Babies who got wide-spectrum antibiotics in their first two years were about 11% more likely to be obese between 2 and 5 than were those who got no such drugs. Babies who had four or more courses of any antibiotics in the first two years were also 11% more likely to be obese in early childhood than those who’d had fewer exposures to antibiotics.

Related blog post:

IBD in Ontario: 1 in 200

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A recent study notes an increasing incidence of and high prevalence of inflammatory bowel disease (IBD) in Ontario, Canada (Inflamm Bowel Dis 2014; 20: 1761-69).

This article notes that between 1999-2008, there was an increased incidence of IBD from 21.3 to 26.2 per 100,000.  This affected most age groups less than 65 years, but increased most rapidly in children younger than 10 years (increased 9.7% per year).  The highest incidence remained in adults aged 20 to 29 years. The overall prevalence in Ontario was estimated to be 1 in 200 overall, which is among the highest in the world.  This study relied on a validated health administrative data consisting of all Ontario residents.

The potential for misclassification bias is discussed and the potential difficulties with administrative health data is detailed in three related editorials (pages 1777-79, 1780-81, 182-83).  The editorials are helpful, in part, because a separate study in the same journal (Inflamm Bowel Dis 2014; 20: 1770-76) indicates that the incidence of Crohn’s disease and Ulcerative Colitis declined in Quebec between 2001-08. However, the authors of this study used less-rigorous methods and had a much shorter “washout” period (two years versus eight years).

At the end of the day, with conflicting studies, there remains some uncertainty with regard to IBD epidemiology.  That being said, the first study notes that “75% of CD studies and 60% of UC studies had reported increased incidence in the adult populations.”

This leads back to the question of what environmental exposures are leading to these changes in incidence.

Bottomline: This article and the associated editorials helps highlight the difficulties of using administrative health data and why many data points are needed to assess the epidemiology of IBD.  In all likelihood, the incidence of IBD is increasing.

Related blog post: Global increases in IBD incidence | gutsandgrowth

 

Deriving Measures of High Value Pediatric Care

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A recent article titled, “How does a gastroenterologist demonstrate value?” (linked to full text) DOI: http://dx.doi.org/10.1016/j.cgh.2014.08.021 provides some insight into what is in store for gastroenterologists as the shift from fee-for-service is influenced by value care initiatives.

Key points:

  • Value = Outcome/Cost
  • Healthcare value = Health of population/Cost
  • “AGA has spent the last 7 years developing measures that focus on outcomes and population management. They are available at http://www.gastro.org/practice/quality-initiatives/performance-measures.”This website provides several measures for hepatitis C, inflammatory bowel disease, endoscopy, and others.
  • For example, endoscopy measures:Measure # 1: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsMeasure #2: Surveillance Colonoscopy Interval for Patients with a History of Colonic Polyps- Avoidance of Inappropriate UseMeasure # 3: Comprehensive Colonoscopy Documentation

As a pediatric gastroenterologist, it is clear that more efforts will be needed for the pediatric population.  While the authors note that “financial pressures will intensify over time,” at the current time there is extremely wide variation on the use of common procedures; in fact, physicians are typically incentivized to perform procedures even in the setting of low yield.  So the first steps will be to define a high value pediatric GI practice.

Another reference with regard to value care (J Pediatr 2014; 165: 650-51) discusses how infectious disease consultations improve outcomes, can decrease costs (length of stay, complications) and improve usage of appropriate antimicrobials.  Another helpful point: “Although common, curbside consultations have been shown to be associated with inferior patient outcomes compared with official bedside consultations.”  This is often due to incomplete or inaccurate data.

Related blog posts:

How to Protect Children From Celiac Disease

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While many parents have asked what they can do to protect their children from celiac disease, the new answer will be more limited than in the past.  Two recent studies from NEJM indicate that timing of gluten introduction and breastfeeding do not appear to significantly influence the development of celiac disease.

Here are the links:

1st Study: Introduction of Gluten (6 months vs 12 months)

  • Results: (n=707) At 5 years of age, the between-group differences were no longer significant for autoimmunity (21% in group A and 20% in group B, P=0.59) or overt disease (16% and 16%, P=0.78 by the log-rank test).
  • CONCLUSIONS: Neither the delayed introduction of gluten nor breast-feeding modified the risk of celiac disease among at-risk infants, although the later introduction of gluten was associated with a delayed onset of disease. A high-risk HLA genotype was an important predictor of disease.

2nd Study: Gluten 16-24 weeks or Delayed  n=944

  • CONCLUSIONS As compared with placebo, the introduction of small quantities of gluten at 16 to 24 weeks of age did not reduce the risk of celiac disease by 3 years of age in this group of high-risk children.

Here’s a story from Boston Globe summarizing findings: Tactics to Prevent Celiac

Bottomline: These well-designed studies argue persuasively against the previously held views that breastfeeding and timing of gluten introduction influence the development of celiac disease.

Related blog posts:

NASPGHAN Educational materials for medical professionals –NASPGHAN Celiac Link

Another Look at Gluten-free Diet for Asymptomatic Celiac

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Previously, a blog entry (Benefits of Gluten-Free Diet for “Asymptomatic” Celiac …) reviewed the abstract (available early online) from Gastroenterol 2014; 147: 610-17.  With the publication of the printed version, some useful commentary (Gastroenterol 2014; 147: 557-59) provides perspective.

Study limitations: small number (20 assigned to gluten-free diet, 20 regular diet).

Key points from editorialists:

  • “This study provides some of the strongest data yet supporting celiac disease screening of family members of patients with celiac disease.  However, important issues must be addressed before screening is widely adopted.”
  • “This [study] leaves us in the uncomfortable position of offering a diagnosis that may improve gastrointestinal symptoms, but simultaneously worsen socialization, offer limited overall change in health-related quality of life, and for which the long-term risk-to-benefit ratios are unknown.”
  • This “makes the cost of a gluten-free loaf of bread for all with asymptomatic celiac disease too high, unless and until additional more substantial benefits can be demonstrated.”

Related blog posts: